Excessive Sweating, Nausea, On Effexor, Cymbalta. Best Drug For GAD?

Hello my name is Dr. J. Clive Spiegel MD and I'm a board-certified psychiatrist and neurologist practicing in the state of New York, USA. Thanks for your excellent question. I will attempt to give you the most comprehensive answer I can. The three medications you have tried, as you yourself stipulate, are the three members of the SNRI family (serotonin & norepinephrine reuptake inhibitors). These agents are all FDA approved for major depressive disorder, but only Effexor and Cymbalta are approved for GAD per se. Does this mean that Pristiq isn't good for treating GAD? Not necessarily. It merely means that Pfizer Hasn't been able to present the FDA with enough data to garner a GAD indication. Also, the FDA has stopped giving pharmaceutical companies post-marketing patent extensions for new indications, which disincentives pharma companies from spending money on these trials and on trying to obtain these indications. Interestingly, most psychiatrists (and primary care physicians) will start patients on SSRIs for GAD first, before using the SNRIs. Why? Because Prozac, Paxil, Celexa, Lexapro, Zoloft are all available as cheaper generic formulations now. Cymbalta and Pristiq remain branded and more expensive in the USA anyway. If you haven't tried one of these SSRIs, then of course this should be seriously discussed between you and your provider. Another factor that patients and physicians forget at times, is that the dosing on these agents is an important factor to moderate. If you haven't taken a high end dose of an agent for six to eight weeks, then you haven't had a proper trial of that agent in either length or strength. The same applies to the SNRIs. Taking an antipsychotic like Seroquel is quite a commitment because its a very strong agent with a myriad of heavy side effects that may outweigh its utility in anxiety disorders. Also the antipsychotic class of agents are NOT indicated for nor approved for anxiety disorders. Yes, they are used off-label for that purpose,but risks may well outweigh benefits. If all else fails, taking a long-acting, low-dose benzodiazepine, like either Xanax XR or Klonopin might be helpful to you. It's something to discuss with your clinician. I hope this helped orient you towards a better outcome. Ask your provider for more information. Thanks for this interesting question. Best of health to you.

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Thanks for the follow up question. Anxiety, unlike depression, tends to be more recalcitrant and recurrent. So to be simple, yes, it's often necessary for people to remain on anti anxiety medications their whole lives. There are no hard and fast rules about this. I've seen patients do well with medications and then enjoy a sustained symptom relief even once off meds. Some patients almost developed a sustained "learned" behavioral response and while
On medications develop a decrease in anxiety that then becomes almost learned and indelible long after the meds are stopped. This is what you refer to as "repairing" the brain. I hope this addressed some of your further concerns.

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